Humans ; Liver Failure ; mortality ; Portasystemic Shunt, Transjugular Intrahepatic ; mortality ; Survival Rate

Transjugular intrahepatic portosystemic shunt (TIPSS) is a promising method of treatment for gastric or esophageal variceal bleeding. This study was performed to determine the prognostic factors contributing to the survival of patients after TIPSS for gastric or esophageal variceal bleeding. One hundred and fifty-five patients who underwent TIPSS between September 1991 and March 2001 were followed up by clinical examination, upper gastrointestinal endoscopy, and Duplex sonography. The mean portohepatic pressure gradient prior to TIPSS was 20.5 +/-9.93 mmHg and dropped to 10.7 +/-6.62 mmHg after TIPSS (p<0.001). The cumulative survival rate was 75.1% at 6 months, 66.6% at 1 yr, 58.4% at 2 yr, and 38.1% at 5 yr. Survival after TIPSS was inversely related to the Child-Pugh classification (p<0.05). The rebleeding rate was 18.3% at 6 months, 21.0% at 1 yr, 32.8% at 2 yr, and 53.1% at 5 yr. The causes of deaths were hepatic failure (53.5%), recurrent variceal bleeding (11.6%), pneumonia (4.6%), sepsis (3.5%), hepatic encephalopathy (2.3%), and unknown (17.4%). Multivariate analysis (Cox proportional hazard model) revealed that the Child-Pugh classification and age were statistically significant independent prognostic factors. In conclusion, TIPSS is an effective method of treatment for variceal bleeding in cases where other treatment modalities including endoscopic therapy are unsuccessful and the most important prognostic factors are preprocedural hepatic reserve (Child-Pugh class) and age.
Adolescent ; Adult ; Endoscopy ; Female ; Fibrosis/diagnosis ; Follow-Up Studies ; Gastrointestinal Hemorrhage/*diagnosis/*mortality/*therapy ; Humans ; Male ; Middle Aged ; *Portasystemic Shunt, Transjugular Intrahepatic ; Prognosis ; Recurrence ; Time Factors ; Treatment Outcome

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been popularized for the treatment of refractory variceal bleeding. The aim of this study was to assess the safety and long-term effect of TIPS in the treatment of variceal bleeding that is not controlled with pharmacological and endoscopic treatment. METHODS: Thirty-six patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) due to refractory variceal bleeding were included in the study. The effectiveness of portal decompression and bleeding control was evaluated. Upper gastrointestinal endoscopy was performed to analyse the degree of varices and portal hypertensive gastropathy (PHG) before TIPS procedure and one to three weeks after TIPS. Angiography was performed in surviving patients, if bleeding recurred, or if ultrasonography or endoscopy suggested stent dysfunction. RESULTS: TIPS were successfully placed in 36 of 38 patients (94.6%). TIPS achieved hemostasis of variceal bleeding in 34 patients (94.4%). Portal venous pressure decreased from an initial average of 28.7 +/- 7.9 to 23.2 +/- 9.4 mmHg after TIPS (p < 0.05). The portosystemic pressure gradient was significantly decreased from 15.5 +/- 6.3 to 7.8 +/- 4.1 mmHg (p < 0.01). The degree of esophagogastric varices and PHG was significantly improved after TIPS. The total length of follow-up was from one day to 54 months (mean: 355 days). The actuarial probability of survival was 83% at one year and 74% at two years. Overall, 16 episodes of stent dysfunction were diagnosed during follow-up. Stent revision by means of angioplasty was successfully performed in 14 of these episodes. CONCLUSION: TIPS is an effective and reliable nonoperative means of lowering portal pressure. This procedure has proved useful in the management of acute variceal bleeding refractory to endoscopic treatment. Surveillance by ultrasonography, endoscopy, and angiographic intervention is useful for the maintenance of shunt patency.
Adult ; Aged ; Esophageal and Gastric Varices/surgery* ; Esophageal and Gastric Varices/complications ; Female ; Gastrointestinal Hemorrhage/surgery* ; Gastrointestinal Hemorrhage/etiology ; Human ; Hypertension, Portal/surgery ; Hypertension, Portal/complications ; Male ; Middle Age ; Portasystemic Shunt, Transjugular Intrahepatic*/mortality ; Portasystemic Shunt, Transjugular Intrahepatic*/adverse effects ; Recurrence ; Survival Rate

It has been approximately 30 years since Child-Turcotte-Pugh score has been used as a predictor of mortality in patients with liver cirrhosis and hepatocellular carcinoma (HCC). Recently, new prognostic models such as Model for End-Stage Liver disease (MELD), Short- and Long-term Prognostic Indices (STPI and LTPI), Rockall score, and Emory score were proposed for predicting survival in patients with liver cirrhosis treated by transjugular intrahepatic portosystemic shunt (TIPS). In MELD scoring, three independent variables which showed a wide range of results including serum creatinine, serum bilirubin and international normalization ratio (INR) of prothrombin time were evaluated in log(e) scale in comparison with simply categorized-into-three scoring system of Child-Turcotte-Pugh. The etiology of liver cirrhosis was applied to the score of MELD: alcoholic or cholestatic, 0; viral or others, 1. Concurrent statistic (C-statistic) of MELD (0.73-0.84) was slightly superior or insignificantly different to that (0.67-0.809) of Child-Turcotte-Pugh score. In February 2002, UNOS status 2a and 2b were replaced with MELD score for priority allocation of liver transplantation. MELD score does not reflect the severity of patients with HCC or metabolic disorders. For assessing prognosis in patients with liver cirrhosis or HCC, there seems little reason to replace the well established Child-Turcotte-Pugh score. Herein the literatures was briefly reviewed.
Bilirubin/blood ; Carcinoma, Hepatocellular/*classification/mortality ; Creatinine/blood ; Humans ; International Normalized Ratio ; Liver Cirrhosis/*classification/mortality/surgery ; Liver Neoplasms/*classification/mortality ; Portasystemic Shunt, Transjugular Intrahepatic ; Prognosis ; ROC Curve ; Risk Factors ; *Severity of Illness Index ; Survival Rate

No abstract available.
Bilirubin/blood ; Carcinoma, Hepatocellular/*classification/mortality ; Creatinine/blood ; Humans ; International Normalized Ratio ; Liver Cirrhosis/*classification/mortality/surgery ; Liver Neoplasms/*classification/mortality ; Portasystemic Shunt, Transjugular Intrahepatic ; Prognosis ; ROC Curve ; Risk Factors ; *Severity of Illness Index ; Survival Rate

OBJECTIVE: This study was designed to determine if existing methods of grading liver function that have been developed in non-Asian patients with cirrhosis can be used to predict mortality in Asian patients treated for refractory variceal hemorrhage by the use of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. MATERIALS AND METHODS: Data for 107 consecutive patients who underwent an emergency TIPS procedure were retrospectively analyzed. Acute physiology and chronic health evaluation (APACHE II), Child-Pugh and model for end-stage liver disease (MELD) scores were calculated. Survival analyses were performed to evaluate the ability of the various models to predict 30-day, 60-day and 360-day mortality. The ability of stratified APACHE II, Child-Pugh, and MELD scores to predict survival was assessed by the use of Kaplan-Meier analysis with the log-rank test. RESULTS: No patient died during the TIPS procedure, but 82 patients died during the follow-up period. Thirty patients died within 30 days after the TIPS procedure; 37 patients died within 60 days and 53 patients died within 360 days. Univariate analysis indicated that hepatorenal syndrome, use of inotropic agents and mechanical ventilation were associated with elevated 30-day mortality (p < 0.05). Multivariate analysis showed that a Child-Pugh score > 11 or an MELD score > 20 predicted increased risk of death at 30, 60 and 360 days (p < 0.05). APACHE II scores could only predict mortality at 360 days (p < 0.05). CONCLUSION: A Child-Pugh score > 11 or an MELD score > 20 are predictive of mortality in Asian patients with refractory variceal hemorrhage treated with the TIPS procedure. An APACHE II score is not predictive of early mortality in this patient population.
Emergency Treatment ; Esophageal and Gastric Varices/*mortality/*surgery ; Female ; Humans ; Male ; Middle Aged ; Portasystemic Shunt, Transjugular Intrahepatic/*mortality ; Predictive Value of Tests ; Prognosis ; Proportional Hazards Models ; ROC Curve ; Retrospective Studies ; Survival Analysis

BACKGROUNDBalanced adjustment of the portal vein shunt volume during a transjugular intrahepatic portosystemic shunt (TIPS) is critical for maintaining liver perfusion and decreasing the incidence of liver insufficiency. A stent-graft is proved to be superior to a bare metal stent (BMS) for the construction of a TIPS. However, the clinical results of the combination application of stents and stent-grafts have not been determined. This study aimed to compare the technique of using a combination of stents and stent-grafts with using a single stent-graft to construct a TIPS.

METHODSFrom April 2011 to November 2014, a total of fifty patients were randomly assigned to a stents-combination group (Group I, n = 28) or a stent-graft group (Group II, n = 22). Primary patency rates were calculated. Clinical data, including the technical success rate, bleeding control results, incidence of encephalopathy, liver function preservation, and survival rate, were assessed.

RESULTSTechnically, the success rate was 100% for both groups. The primary patency rates at 1, 2, and 3 years for Group I were 96%, 84%, and 77%, respectively; for Group II, they were 90%, 90%, and 78%, respectively. The survival rates at 1, 2, and 3 years for Group I were 79%, 74%, and 68%, respectively; for Group II, they were 82%, 82%, and 74%, respectively. The incidence of hepatic encephalopathy was 14.3% for Group I and 13.6% for Group II. The Child-Pugh score in Group I was stable at the end of the follow-up but had significantly increased in Group II (t = -2.474, P = 0.022).

CONCLUSIONSThe construction of a TIPS with either the single stent-graft or BMS/stent-graft combination is effective for controlling variceal bleeding. The BMS/stent-graft combination technique is superior to the stent-graft technique in terms of hepatic function preservation indicated by the Child-Pugh score. However, considering the clinical results of the TIPS, the two techniques are comparable in their primary shunt patency, incidence of encephalopathy and patient survival during the long-term follow-up.

Aged ; Female ; Hepatic Encephalopathy ; diagnosis ; etiology ; Humans ; Hypertension, Portal ; complications ; mortality ; surgery ; Male ; Middle Aged ; Polytetrafluoroethylene ; Portal Vein ; surgery ; Portasystemic Shunt, Transjugular Intrahepatic ; adverse effects ; methods ; Postoperative Complications ; Prospective Studies ; Stents ; Treatment Outcome

BACKGROUND/AIMS: This retrospective study assessed the clinical outcome of a transjugular intrahepatic portosystemic shunt (TIPS) procedure for managing portal hypertension in Koreans with liver cirrhosis. METHODS: Between January 2003 and July 2013, 230 patients received a TIPS in 13 university-based hospitals. RESULTS: Of the 229 (99.6%) patients who successfully underwent TIPS placement, 142 received a TIPS for variceal bleeding, 84 for refractory ascites, and 3 for other indications. The follow-up period was 24.9+/-30.2 months (mean+/-SD), 74.7% of the stents were covered, and the primary patency rate at the 1-year follow-up was 78.7%. Hemorrhage occurred in 30 (21.1%) patients during follow-up; of these, 28 (93.3%) cases of rebleeding were associated with stent dysfunction. Fifty-four (23.6%) patients developed new hepatic encephalopathy, and most of these patients were successfully managed conservatively. The cumulative survival rates at 1, 6, 12, and 24 months were 87.5%, 75.0%, 66.8%, and 57.5%, respectively. A high Model for End-Stage Liver Disease (MELD) score was significantly associated with the risk of death within the first month after receiving a TIPS (P=0.018). Old age (P<0.001), indication for a TIPS (ascites vs. bleeding, P=0.005), low serum albumin (P<0.001), and high MELD score (P=0.006) were associated with overall mortality. CONCLUSIONS: A high MELD score was found to be significantly associated with early and overall mortality rate in TIPS patients. Determining the appropriate indication is warranted to improve survival in these patients.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Asian Continental Ancestry Group ; End Stage Liver Disease/pathology ; Female ; Follow-Up Studies ; Hemorrhage/etiology ; Hepatic Encephalopathy/etiology ; Hospitals, University ; Humans ; Hypertension, Portal/*diagnosis/mortality/surgery ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Odds Ratio ; *Portasystemic Shunt, Transjugular Intrahepatic ; Republic of Korea ; Retrospective Studies ; Risk Factors ; Severity of Illness Index ; Survival Rate ; Treatment Outcome ; Young Adult